School Insurance of Florida

Insuring Florida's kids for over 40 years.

Tuesday 19th of October 2021 02:21 AM

Affordable Insurance Protection!

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Orange County Public Schools

Maximum Benefits/Provisions/Exclusions

EXCESS INSURANCE

The Certificate of Insurance summarizes the policy provisions and benefits. This policy will not pay 100% of all incurred medical expenses. Policy limits and exclusions apply. Policy benefits are payable, subject to the limits specified below, for accidental bodily injury resulting from a covered accident (or covered illness if the optional In-Hospital Sickness Benefit Option is purchased). The company will pay the reasonable cost of covered eligible medical charges not to exceed the maximum benefits listed in the policy (summarized in this website). The maximum benefit payable for any one covered accident is $25,000.00.

The maximum benefit payable under the optional In-Hospital Sickness Benefit Plan Option is $5,000.00 in the aggregate for all covered in-hospital expenses due to covered illness or disease. First medical treatment by a licensed physician or dentist for a covered condition must be obtained within thirty (30) days from the original date of the covered injury or condition to be eligible for policy benefits. The company will pay for covered medical charges for treatment and care rendered within 52 weeks after the date of a covered accident or condition.

POLICY DEFINITIONS                                                      PURCHASE INSURANCE NOW!!                                                                  

“Covered Accident” means bodily injury of the insured that results directly and independently of all other causes from a covered accident occurring while the policy is in force. Self-inflicted injuries caused by prolonged over exertion, stress or strain, or disease process or aggravation of an existing condition is expressly excluded from coverage under the accident policy. “Covered Charges” means reasonable charges which are not in excess of usual and customary charges; not in excess of the maximum benefit amount payable for services specified below; services and supplies which are not excluded from coverage; and services and supplies which are a medical necessity for treatment of the covered accident. “Pre-Existing Condition” means any physical condition for which the existence of symptoms would cause a normally prudent person to seek medical care or advice. Physical condition includes any complication or residual of a prior illness, condition or disease the person was advised or treated for in the six (6) months before the effective date of the Insured’s coverage under the policy. “Sickness” means an illness or disease for which symptoms first originate and for which medical treatment is rendered by a physician while this Endorsement is in force. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. “Hospital” means a licensed or properly accredited general hospital which is open at all times and operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients under the supervision of one (1) or more legally qualified physicians available at all times with continuous, twenty-four (24) hour nursing services by Registered Nurses on duty or call. “Hospital” does not mean a facility that is primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating mental or nervous disorders, alcoholics or drug addicts. “At-School Accident Coverage” applies while a covered person is in attendance at the school during the hours and on the days that school is in session; participating in activities, except as a spectator, which are exclusively school-funded, school-sponsored, school-supervised and scheduled by the school on or away from school premises, during or after school hours or school-sponsored religious instruction; traveling directly and without interruption to or from the covered person’s residence and the school for regular school sessions or such travel time as is required, however, not to exceed one (1) hour before the regular school classes begin and not more than one (1) hour after school is dismissed; no coverage is provided while a person is participating in interscholastic sports practice or competition at or away from school premises. “24-Hour Accident Coverage” includes “At-School Coverage” and extends coverage to twenty-four (24) hours per day while a covered person is at home, school or on vacation. Under the 24- hour coverage plan, the same benefits, limitations and exclusions of the “At-School Coverage” plan will apply. No benefits are payable for practicing for or participating in interscholastic or organized league sports (for information about interscholastic sports coverage,CLICK HERE). Additional policy terms and provisions apply which are stated in the Master Blanket Accident Insurance Policy issued to the school district and on file for your review. “Effects of Other Coverage” means the insurance coverage provided under the policy shall be “EXCESS” to any other collectible insurance or plans, including but not limited to auto P.I.P. and auto medical payments, HMOs or PPOs, subject to limits stated in the policy when total charges for treatment of a covered accident are in excess of $250.00. Third party subrogation rights are reserved. Total payments by all insurance plans, including HMOs or PPOs, shall never exceed the total medical expenses incurred.

INSURANCE MAXIMUM BENEFITS                                        Click Here to Purchase Insurance Now

Inpatient Hospital Benefits: For daily Semi-Private Room & Board including all miscellaneous charges, supplies, services, operating room, implantable devices, etc., the policy pays up to $2,000.00 per day; While in Intensive Care, including all miscellaneous charges, supplies, services, operating room, implantable devices, etc., the policy pays up to $3,000.00 per day.

Outpatient Hospital, Emergency Room or Same-Day Surgi-Center Benefits: If outpatient major surgery is performed requiring general anesthesia, the policy pays up to $6,500.00 for all hospital or Surgi-Center billed supplies, services and implantable devices; the policy will pay up to $500 for use of the hospital’s Emergency Room, (Emergency Room benefit applies to injuries requiring emergency treatment within 72 hours of an accident).

Physician’s Non-Surgical Office or Hospital visits and Consultations: Initial non-surgical visit payable up to $68.00; up to $56 paid for necessary non-surgical follow-up visits; if a Consultation with a Specialist is required, the policy will pay up to $116.00 for one visit to a Specialist; Physician Assistant Visits: $48.00.

Surgery Fees: Benefits for the primary surgeon are paid based upon the fee amounts stated in the 2008 Florida Work Comp Fee Schedule.  Assistant Surgeon’s Benefit: (when medically necessary) is payable up to 25% of the primary surgeon’s allowable benefit.

Professional Anesthesiology Administration Benefit: is payable up to 20% of the primary surgeon’s allowable benefit.

Policy limits for X-Rays, MRI, CAT, other Scans and Lab (including interpretation and reading fees): All X-Rays: $250.00; MRI, CAT and other SCANS: $500.00 in the aggregate; Laboratory Expense: Up to $150.00.

Outpatient Physical Therapy Treatment Visits: Limited to 10 visits per covered injury not to exceed $40.00 per treatment visit.

Orthopedic Appliances: (When used for rehabilitation purposes): up to $300.00.

Drug Store Prescriptions (when prescribed by an M.D. for a covered accident): Up to $100.00.

Emergency Ambulance Service: Up to $500.00 (Air or Ground)

Dental Services: (Amount payable per injured tooth (includes x-rays): up to $500.00 for treatment of each injured tooth.

EXCLUSIONS - WHAT THE POLICY DOES NOT COVER

1. The practice or play of interscholastic sports including travel to or from such practice or play (For information about interscholastic sports coverage, CLICK HERE). Participation in any organized sports camps, league practices or competitions that are not exclusively funded, scheduled and supervised by the Member school district Board of Education to which the Policy is issued. Participation in organized classes, practices or competitions in boxing, wrestling, self-defense, or martial arts, including but not limited to Karate, Aikido, Tae Kwon Do, Jujitsu, Kung Fu, kickboxing or weapons training unless the organized program is exclusively sponsored, funded, and scheduled by the Member school district Board of Education to which the Policy is issued,  and directly supervised by a Member school employee.

2. Damage to other than whole, sound, vital and natural teeth or to existing dental bridges, crowns, restorations or braces; orthodontic procedure and services. Treatment for injury or fracture of tooth caused either by decay, infection or the breakdown of a dental restoration.

3. Pathological fractures, stress fractures, boils, athlete’s foot, impetigo or similar skin infection, rashes, poisonous vegetation reactions, warts, blisters, calluses, cramps, muscle spasms, allergies or allergic reactions, ingrown nails, appendicitis, hernia of any kind, however caused; infections occurring other than as a result of such injury; detached retina; or psychiatric care.

4. Any form of illness, sickness or disease including but not limited to the following: Perthes’ Disease, Osgood-Schlatter’s Disease, Osteomyelitis, Osteochondritis, Osteogenesis Imperfecta, Slipped Capital Femoral Epiphysis, Thrombophlebitis, Hysterical Reactions, or similar conditions (unless the In-Hospital Sickness Benefit Option is purchased).

5. Any form of fighting or brawling or criminal or felonious assault or the Insured being engaged in an illegal occupation. Intentionally self-inflicted injury.

6. Services or treatment rendered as a part of the member school service by a hospital, physician, or person employed or retained by the member, or by a person related to the Insured by blood or marriage.

7. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any motorized or engine-driven vehicle. Eligible medical expenses not collectible from other valid coverage will be payable up to $1,000.00.

8. War or any act of war (raids by air, land or sea shall be deemed act of war), civil disobedience, plots or insurrection.

9. Injuries sustained by the Insured for which benefits are payable under any Workers’ Compensation or Employer Liability Laws, or while engaging in activity for monetary gain from sources other than the Member.

10. Aviation in any form except while the Insured is riding as a passenger in a licensed airplane provided by an incorporated passenger carrier on a regularly scheduled passenger flight and route.

11. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any snowmobile, all-terrain vehicle, or two (2) or three (3) wheeled motor vehicle.

12. The use of or while under the influence of drugs unless administered as prescribed by a physician.

13. The existence or aggravation of physical or mental infirmity, condition or disease, whether infectious, congenital, secondary or acquired in origin. Conditions or the aggravation of conditions that originated prior to the Insured’s Effective Date, not to exceed $500.00.

14. Expense resulting from participating in activities for which benefits would be payable, in the absence of this insurance, under any high school or association-sponsored catastrophe sports accident policy or trust fund is expressly excluded from coverage.

15. Snow skiing, snow tubing, snowboarding, water skiing, wake boarding, surf boarding, hydro-sliding, jet skiing or using any "personal watercraft" as defined by Florida statutes. Injury as a result of skate boarding.

16. Prescription drugs, injections, miscellaneous supplies and medications, except those administered while hospital-confined or when treated in the emergency room.

17. Any expense for which a benefit is not listed.

Additional exclusions for the optional In-Hospital Sickness Benefit: No benefits payable due to pregnancy, child birth, abortion, drug or alcohol intoxication, addiction or treatment expense; mental illness, emotional disorders, or psychiatric care; dental care for any cause including TMJ; any out-patient visit, treatment or service; any pre-existing condition or recurrence thereof; any expense due to accidental bodily injury.

A certificate of insurance summarizes the provisions and benefits of the policy # 09-0139-2022 (filed form # LRS-8985-0100-FL). Any difference between the policy and the certificate will be settled according to the provisions of the policy.

Click Here for information about How to File a Claim/ Seeking Medical Treatment/ Q & A